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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 U SP-0to-6T <br /> OWNER/OPERATOR �- <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS S //�� -�/-t7 C 5 Cn/ <br /> 1 t It Number Direction ��I O Street Name I CI �� L zie <br /> HOME or MAILING ADDRESS Different from Site Address) .[��(,l 1,/I-r/�'t/'T <br /> ..7� Street Number V V v- VM •$tr�et Name <br /> CITY S C I( 46 YI STATE /� /I ZIP �J'��® <br /> PHONE#7 I� Y ExT• APN# LAND USE APPLICATION# r <br /> (20 6� 1b <br /> PHONE#2 _ EKT• BOS DISTRICT LOCATION CODE <br /> ( r � 8 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> J CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# EXT. <br /> 6 <br /> HOME Or MAILING AppRE5S (^ U, 1h Vk L i (� ) <br /> CITY •V/ ` �"l•l •-r STATE ZIP O <br /> KbA <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> PLICANT'S SIGNATURE: _/ ( ; ( p \) 4�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER <br /> AGER❑OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thejNlpe time it is <br /> provided to me or my representative. n ',,� PIy <br /> TYPE OF SERVICE REQUESTED: 60 WI A( <br /> COMMENTS; <br /> 4 <br /> R'NND <br /> SO2O0 <br /> 2I1YD �7, <br /> ij <br /> eNt <br /> ACCEPTED BY: EMPLOYEE M I ,po DATE: 91 <br /> ASSIGNED TO: EMPLOYEE M Lys�(G DATE: •2 ,j <br /> Date Service Completed (if already Completed): SERVICE CODE:POU <br /> PI J <br /> LT <br /> Fee Amount: (� Amount Pai �S�a Paymeentt�'Date S Z J <br /> Payment Type 'r Invoice# Check# /�2S 9 Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 C6q!52� <br /> / <br /> J <br />